Pediatric Cardiac Intensive Care –

Cardiovascular Management: Nursing

Considerations

Patricia Lincoln, Dorothy Beke, Nancy Braudis,

Elizabeth Leonard, Sherry Pye, and Elisabeth Smith

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Postoperative Admission to the Pediatric Cardiac Intensive Care Unit . . . . . . . . . . . . 2
“Fast-Track” Pediatric Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Cardiac Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Delayed Sternal Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Use of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Abstract

P. Lincoln (*) · D. Beke Cardiac care of the patient in the PCICU is a

Clinical Nurse Specialist, Cardiac Intensive Care Unit, complex process. This chapter describes
Boston Children’s Hospital, Boston, MA, USA salient aspects of nursing care associated spe-
e-mail: patricia.lincoln@childrens.harvard.edu; Dorothy.
beke@childrens.harvard.edu cifically with cardiovascular management,
delayed sternal closure, and the use of extra-
N. Braudis
Advanced Practice RN II, Cardiac Intensive Care Unit, corporeal membrane oxygenation. Also
Boston Children’s Hospital, Boston, MA, USA included is the discussion regarding implica-
e-mail: Nancy.braudis@cardio.chboston.org tions of fast-track pathway of care. Addition-
E. Leonard ally, this chapter will incorporate examples of
Critical and Cardiorespiratory Unit, Great Ormond Street communication tools utilized during patient
Hospital for Children NHS Foundation Trust, London, UK handoffs to foster improved care and safety,
e-mail: elizabeth.leonard@gosh.nhs.uk
in specific centers.
S. Pye
Cardiac Transplant Coordinator, Department of Pediatric,
Cardiology, University of Arkansas for Medical Sciences, Keywords
Arkansas Children’s Hospital, Little Rock, AR, USA
Admission process · Arrhythmias · Cardiac
e-mail: sepye@uams.edu
output · Delayed sternal closure · ECMO ·
E. Smith
Fast-track protocols · Hemodynamic
Great Ormond Street Hospital for Children NHS
Foundation Trust, London, UK monitoring · Low cardiac output syndrome
e-mail: smithe1@gosh.nhs.uk; liz.smith@gosh.nhs.uk

© Springer-Verlag London Ltd., part of Springer Nature 2020 1

E. M. Da Cruz et al. (eds.), Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care,
https://doi.org/10.1007/978-1-4471-4999-6_196-2
2 P. Lincoln et al.
(LCOS) · Patient handoffs · Pulmonary
hypertension
Introduction
Cardiac care of the patient in the PCICU is a
complex process. This chapter describes salient
aspects of nursing care associated specifically
with cardiovascular management, delayed sternal
closure, and the use of extracorporeal membrane
oxygenation. Also included is the discussion
regarding the implications of a fast-track pathway.
Additionally, this chapter will incorporate exam-
ples of communication tools utilized during
patient handoffs to foster improved care and
safety.
Postoperative Admission
to the Pediatric Cardiac Intensive
Care Unit
Much work has led to the development of a sys-
tem for admissions to the PCICU in which the
nurse is supported, the patient safe, the family is
informed, and all members of the multi-
disciplinary team receive the handover informa-
tion needed to optimize the patient’s stay in
intensive care. It is important to explain how this
has been achieved, so this information may be
transferred to multiple units and situations.
One of the most important factors is the knowl-
edge base and preparation of the family and
patient that is to be admitted. The fetal care team
will work with families during pregnancy and
ensure seamless communication between time of
delivery and admission to the PCICU, preparing
the family and ensuring the clinical team is
updated on the baby’s condition. For the same
day admission (SDA) patient, the nursing team
endeavors to meet the parents and child before-
hand. Often, there will be a visit to the PCICU on a
preadmission visit for all families. This allows for
the assessment of individual needs and to ensure
that the family is familiar with their potential
pathway of care. For the SDA patient, on the
morning of the operation, the PCICU nurse may
visit and introduce themselves to the child and
family. Research has shown that this may signif-
icantly reduce stress for parents, as well as for the
child [1].
The preadmission visit has high importance for
the SDA patient, allowing the parents to discuss
any worries and permitting observation of the
child for age-appropriate behavior and level of
activity, presence of cyanosis or respiratory dis-
tress, or any other concerns. Expected dates of
discharge from PCICU, intermediate care area,
and the ward to home are discussed [2]. Planning
the estimated days of intensive care admission
allows the family to ensure they have local
arrangements and when they should anticipate
discharge.
Admission to the PCICU requires focused
planning and preparation. The bed space, equip-
ment, and needed supplies are obtained in antici-
pation of an emergency situation as well as
ensuring the availability of the tools required to
deliver effective and timely care. Oxygen, suc-
tion, and other safety equipment are checked and
available in the bed space. Standardized fluids and
medications are prepared, and early entry into the
computerized electronic charting is established.
The mechanical ventilator is set up with settings
from the operating room, allowing the system to
be prechecked.
Safety underlines all the care in the PCICU –
from the most junior member of staff to the unit
lead. This is illustrated in the unit handover policy,
developed from the pit stop process of Formula
1 motor racing where handover, safety, and team-
work were observed and those transferable skills
to the healthcare setting were noted. Each individ-
ual has a defined role, reducing variability and,
therefore, potential error within the system [3].
Phases of clinical handover
Phase Event Action
0 Patient transfer Checklist of ventilator
from the settings and monitoring
operating room lines recorded for set
up/update for unit team
and needed equipment
1 Equipment and Handover of all
technical equipment and
handover monitoring
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations 3

Phase Event Action Mindful of the anxiety of the waiting parents,

2 Information phase Defined role for each they are permitted to be with their child at the
team member. bedside. Families may stay for as long as they
Anesthetist reviews wish [5]. Recent research [6] highlighted the
events of intubation,
ventilation, and bypass immediate postoperative period as one of the
and any observations most stressful times for parents. The management
during the operation. The of pain is of great concern to families, and contin-
surgeon comments on the ual assessment using an appropriate comfort/pain
surgical procedure and
any intraoperative scale [7] ensures adequate pain relief and the
problems administration of prescribed medications. Distress
3 Discussion phase The anticipated recovery may be minimized using comfort measures suit-
plan is verbalized by the able to the patient’s age and condition, and there is
intensive care physician. also access to the hospital pain control team and
A decision on the
appropriate pathway or ongoing anesthesia staff support.
other care/intervention is After the initial admission and handover, all
discussed. Two nurses communication is standardized using a uniform
assist – one concentrates communication tool, SBAR [8, 9]:
on the verbal report from
the operating room team
and the other performs Situation
the initial patient Background
assessment and Assessment
admission of the patient
to the PCICU (obtaining Recommendation
vital signs and laboratory
blood specimens and After the patient has been admitted and stabi-
connects and records
drainage from chest
lized, it is the role of all team members to ensure
drains) the child and family progress through to recovery
[10–12].
Once the handover is completed, the bedside
nurse’s main concern is the status of the patient. A
full physical examination is completed – assess- “Fast-Track” Pediatric Cardiac Surgery
ment of equal breath sounds, bilateral chest move-
ment, presence of air leak around the endotracheal Fast-track cardiac surgery has been defined as a
tube, and amount and characteristics of chest reduction in the patient journey time from admis-
drainage. Hemodynamic assessment includes sion to discharge [13, 14]. This encompasses a
heart rate, blood pressure, heart-filling pressures, reduction in ventilation time, possible same day
peripheral pulses, and color/temperature of discharge to an intermediate care unit from the
peripheral limbs. Pupils are checked for size and PCICU, and early de-intensifying. This pathway,
the reaction time. Assessment of capillary refill is however, is dictated by the clinical condition of
performed both peripherally and centrally. Pro- the child, safety being of paramount importance.
longed capillary refill and cool extremities may Working in emerging economies has provided
indicate a low cardiac output state [4]. A chest insights and an “informal” evidence base for fast-
radiograph (CXR), 12-lead electrocardiogram track-type service delivery, within a health provi-
(ECG), and sometimes an additional echocardio- sion system where resources and time may be
gram (ECHO) are required within the first hour constrained. In addition, exposure to the success
postoperatively to help support the direction of these programs by the multiprofessional team
of care. has been a positive influence on the development
of this service within pediatric cardiac services in
4 P. Lincoln et al.
the National Health Service (NHS) in England.
Other factors for support are:
Cardiac Nurse Practitioner (CNP) role
development
Joint cardiac conferencing and agreed multi-
professional criteria
Anticipated recovery pathways to standardize
care delivery
Preadmission assessment
Timing of surgery
Use of modern anesthesia agents
Improvements in surgical techniques
Improvements in cardiopulmonary bypass tech-
niques, including ultrafiltration at the end of
cardiopulmonary bypass [15]
Parental presence during recovery
Intensive care developments, including short act-
ing opiates and advanced pain management
skills
Collectively, these factors have led to a reduc-
tion in pediatric mortality and morbidity with
subsequent cost reduction implications. The
delivery of cost-efficient care is now an additional
variable when measuring and comparing surgical
outcomes [16–18]. Below is one example of a
“fast-track model”:
Eligibility for the fast-track pathway requires:
Low-complexity cardiac surgery, for example,
repair of atrial septal defect (ASD), ventricular
septal defect (VSD), and subaortic stenosis
No major comorbidities that may involve a higher
postoperative risk
Patient otherwise in good general health and
asymptomatic
Patient over 6 months of age
Limiting criteria for the fast-track pathway
include:
Small infant with increased potential to fail early
extubation
Complex surgery or staged palliation surgery
The presence of other noncardiac issues
Candidates for fast track will be done as first
cases in the operating room (OR) and transitioned
by a specific time to an intermediate care unit. The
preadmission assessment is obtained within
1 month of the planned surgery. Patient and family
teaching done preoperatively is essential in reduc-
ing postoperative anxiety and enabling the chil-
dren to more easily accept their subsequent
medical care [2]. On the day of surgery, a pre-
surgery, clinical assessment is performed by the
CNP and anesthesiologist. This meeting also
ensures that the anesthetist and clinical team are
aware of the plans for fast-track surgery, including
mode of operative sedation and analgesia.
Although a large component of fast-track sur-
gery is the reduction of mechanical ventilation
time and early extubation, it is important to rec-
ognize that fast track and early extubation are not
synonymous [17]. Extubations performed in the
recovery room before return to the PCICU do not
necessarily decrease recovery time in that unit.
The majority of the postoperative care for the
fast track patient does not differ from our stan-
dardized cardiac postoperative care. Excellent
clinical assessment skills and knowledge of the
individual child are important for continued pro-
gress through the care pathway. This supports the
provision of a dedicated team to lead this care
pathway, staff that is familiar with the differences
in parameters and timing of events.
Prior to leaving the operating room, the sur-
geon or the anesthetist infiltrates the sternal
wound with local anesthetic. This provides addi-
tional pain relief with reduced use of opiates and
may be effective for up to 8 h, potentially contrib-
uting to early extubation. A continuous incisional
infusion of local anesthetic has been reported by
the Congenital Heart Institute of Miami Chil-
dren’s Hospital and Arnold Palmer Hospital for
Children, Miami, Florida, to reduce the length of
stay, amount of sedation, and antiemetics
[19]. The child will also receive intravenous
non-opioid pain medication until tolerating oral
intake, then oral pain medication and nonsteroidal
anti-inflammatory [20, 21].
If the child is not extubated prior to leaving the
operating room, experience demonstrates that
extubation occurs within 4 h postoperatively.
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
These patient decisions utilize advanced nursing
education and assessment skills, increased auton-
omy of nursing practice, and caseload manage-
ment combined with communication briefings
with relevant nursing and medical teams. At 4 h
postoperatively, the child is assessed for same day
discharge to an intermediate care unit.
Events that may prevent discharge to interme-
diate care unit:
Postextubation stridor/respiratory compromise
Bleeding from chest drains
Arrhythmia
Bed availability
A Children’s Early Warning System (CEWS)
[22] and a standardized communication tool such
as SBARD (situation, background, assessment,
recommendation, and decision) should be used
to alert teams to early changes in a child’s clinical
condition and ensure accurate, consistent, and
safe communication between teams. These tools
clarify what and how information is communi-
cated between members of the team and also
help develop teamwork and foster a culture of
patient safety.
On postoperative day 2, the child is rapidly
assessed for de-intensification from the interme-
diate care unit. Strong clinical assessment skills,
knowledge of the process, and decision-making
are key to the safety of this process. An arterial
blood gas review with no concerns allows the
arterial line to be removed. Transthoracic pacing
wires are removed without an additional ECG if
there is no evidence of arrhythmia or need for
external cardiac pacing. Peripheral IV access is
assured. Chest drain removal is assessed on pre-
defined criteria from the anticipated care pathway
and local guidelines. No routine pre- or post-chest
drain removal CXR is performed unless there is
clinical reason [23].
It is the responsibility of the advanced practice
nurse to assess the child’s suitability for discharge
home and to ensure they have all relevant dis-
charge information, education, and emergency
contact information. Prior to the child’s discharge,
usually on postoperative day 3, there is a review
5
and agreement from the multiprofessional team,
as well as the child and family, regarding dis-
charge suitability and any ongoing medical
concerns.
As a safety net to a rapid process of care, a
follow-up phone call will be placed to the family
within 48 h of discharge. This early communica-
tion and update with the child and family is a
critical safety step in a rapid discharge process.
Assessment is made of family management of
care, and any questions regarding medications,
analgesia, surgical wounds, feeding, or general
concerns that may have arisen since discharge
are addressed. Any acute issues will continue to
be monitored until the next clinic appointment.
Cardiac Postoperative Care
The nursing considerations involved in providing
exceptional postoperative care of the pediatric
cardiac surgery patient necessitate a full under-
standing of the patient’s cardiac defect, the impact
of the defect on other body systems, and the
patient’s treatment, repair, or palliation. Nursing
focus is on vigilant patient monitoring, anticipat-
ing potential problems, and providing care with a
proactive preventative approach.
Cardiac output is defined as the amount of
blood ejected from the heart in 1 min. It is a
function of heart rate multiplied by stroke volume.
Stroke volume consists of preload, afterload, and
contractility. Cardiac index, often used in pediat-
rics, is calculated as cardiac output divided by
body surface area and expressed as liters/minute/
meter2 [24]. Assessment of cardiac output
includes evaluating heart rate and rhythm, blood
pressure, intracardiac filling pressures, core tem-
perature, peripheral perfusion, urine output, acid–
base balance, lactic acid excretion, and oxygen
consumption [25].
Preload is the volume of blood in the left ven-
tricle prior to ejection and may be indirectly
assessed by monitoring atrial filling pressures.
Preload may be decreased with excessive fluid
loss or inadequate volume replacement. This
may occur during rewarming and subsequent
vasodilation, postoperative bleeding, diuresis, or
6 P. Lincoln et al.
capillary leak syndrome following cardiopulmo-
nary bypass (CPB) [26]. Bleeding and abnormal
coagulation factors may be corrected by giving
fresh frozen plasma, cryoprecipitate, or other
blood products. Packed red blood cells may be
given to correct a low hematocrit and stabilize
intravascular volume. Hypovolemia resulting
from rewarming, capillary leak, or diuresis may
be managed with colloid or crystalloid replace-
ment. Fluid boluses are administered cautiously
while assessing atrial filling pressure, arterial
blood pressure, peripheral edema, liver distention,
and fontanel fullness. Preload may be increased
from myocardial dysfunction, intravascular over-
load, tamponade physiology, tachyarrhythmia, or
increased pulmonary vascular resistance (PVR)
and systemic vascular resistance (SVR).
Afterload is resistance to ejection of blood
from either or both ventricles predisposing the
myocardium to elevations in PVR and/or SVR.
Common causes of increased PVR and SVR in the
postoperative cardiac surgical patient are multi-
factorial and may include hypoxemia, acidosis,
hypothermia, pain, or obstruction to blood flow
from the ventricles. Systemic vascular resistance
may increase in response to a low cardiac output
state or as a result of high-dose inotropic medica-
tions. Increased PVR may result from both acute
and chronic states. Neonates in particular often
have a highly reactive pulmonary vascular bed
resulting in elevations in PVR. Treatment strate-
gies to decrease afterload resistance include
avoidance of common triggers and manipulation
of mechanical ventilation to reduce PVR, admin-
istration of sedatives and analgesics to blunt the
stress response, and use of vasodilating agents.
In addition to preload and afterload, other
determinants of cardiac output include heart rate,
conduction, and contractility. Ventricular rate
varies according to size, age, and patient condition
and may be influenced by autonomic, humeral,
and environmental stimuli [27]. Cardiac output is
more dependent on heart rate due to limited stroke
volumes in smaller, pediatric patients as compared
with adults. Though a neonate may tolerate an
elevated heart rate, decreased myocardial compli-
ance predisposes the neonatal heart to increased
sensitivity to SVR and limited response to
elevations in preload [25]. Tachycardia may limit
ventricular filling and decrease cardiac output
when heart rate exceeds 220 beats per minute in
the neonate or 180 beats per minute in the pediat-
ric patient [27].
Cardiac contractility refers to the ability of the
myocardium to produce force based on preload
and alterations in sympathetic stimulation of the
ventricles [27]. Postoperative factors leading to
impaired myocardial contractility include medica-
tions and anesthetic agents, hypoxemia, acidosis,
ischemic insult, cardiac tamponade,
ventriculotomy incision, and residual anatomic
cardiac lesions [28]. Inotropic support and afterl-
oad reduction should be optimized to support
impaired cardiac contractility and low cardiac
output. Decreased contractility from cardiac
tamponade requires prompt intervention includ-
ing maintaining patency of chest tubes and possi-
ble emergent mediastinal exploration.
Low cardiac output syndrome (LCOS) has
been reported in approximately 24% of neonates
following congenital heart surgery [29]. The low-
est cardiac index occurred 6–12 h after CPB. The
decrease in cardiac index was associated with a
significant rise in SVR and PVR over baseline
values. Signs of LCOS include tachycardia, hypo-
tension, decreased urine output, poor systemic
perfusion, increased core temperature, elevated
lactate, and decreased mixed venous oxygen sat-
uration [25, 30]. Potential sources of low cardiac
output include (1) residual cardiac defect, (2) myo-
cardial ischemia, (3) inadequate myocardial pro-
tection during CPB, (4) inflammatory response,
(5) increased SVR and PVR, (6) arrhythmias,
(7) cardiac tamponade, and (8) ventriculotomy
[28, 31, 32]. Early recognition and management
of a low-output state are essential to minimize
morbidity and mortality.
Measures to improve cardiac output include
volume management to maintain adequate pre-
load, vasoactive infusions to improve cardiac con-
tractility, and afterload reduction to minimize the
stress on the myocardium. Dopamine or low-dose
epinephrine may be used for inotropic support to
improve myocardial contractility and reverse
hypotension related to LCOS. However, catechol-
amine infusions are not without risk and may
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
cause a tachyarrhythmia, increased myocardial
oxygen consumption, and increased
end-diastolic pressure and afterload
[31]. Milrinone is a phosphodiesterase inhibitor
that has both inotropic effects and afterload-
reducing properties and may prevent or improve
the management of LCOS. In a multicenter study,
infants receiving a high-dose infusion of
Milrinone (0.75 mcg/kg/min) were found to have
a 64% relative risk reduction in the development
of LCOS in the postoperative period following
congenital heart surgery [32].
Efforts to manipulate SVR and PVR are crucial
to maintaining hemodynamic stability in the post-
operative period. Factors that may contribute to an
increase in SVR and PVR such as inadequate pain
control, hypoxia, acidosis, and hypothermia
should be effectively treated to further reduce the
risk of developing LCOS. Adjunct therapies
include mechanical ventilation, neuromuscular
blockade, adequate sedation, and arrhythmia
management. Atrioventricular (AV) synchrony is
critical to maintaining adequate cardiac output in
the postoperative period. Treatment includes pac-
ing strategies and the use of antiarrhythmic med-
ications to optimize cardiac function.
The use of extracorporeal membrane oxygen-
ation (ECMO) is indicated for progressive myo-
cardial dysfunction refractory to conventional
therapies, failure to wean from CPB, or cardiac
arrest [33, 34]. ECMO may be used to provide
short-term support for the myocardium or as a
bridge to transplant.
Pediatric patients with congenital heart disease
are prone to developing arrhythmias from under-
lying cardiac disease, surgical techniques, medi-
cal management, and electrolyte imbalance
[35]. The incidence of arrhythmias in pediatric
patients ranges from 8% to 29% in the postoper-
ative period [35–37]. The loss of atrioventricular
(AV) synchrony associated with many arrhyth-
mias may result in a 20–30% reduction in cardiac
output [28]. Poor heart rate variability or cannon
waves on a left atrial (LA) tracing may be impor-
tant indicators of an abnormal rhythm. Temporary
epicardial pacing wires are often placed following
congenital heart surgery for the diagnosis and
management of arrhythmias [38, 39]. Accurate
7
diagnosis and prompt management are essential
to reduce the effects of low cardiac output related
to an arrhythmia.
Common arrhythmias identified in the postop-
erative period following pediatric heart surgery
are supraventricular tachycardia, ventricular
tachycardia, junctional ectopic tachycardia, and
complete heart block [40]. Supraventricular
tachycardia (SVT) is a reentry tachycardia with
an abrupt onset and regular rate. It is often poorly
tolerated in infants but may resolve with vagal
maneuvers or overdrive pacing. Adenosine is a
first-line drug for SVT in a stable patient
[41]. However, synchronized cardioversion may
be necessary in hemodynamically unstable
patients. Ventricular arrhythmias are less common
in young children but increase in frequency in
teenagers and young adults. The risk for develop-
ing ventricular arrhythmias increases with acido-
sis, low cardiac output, electrolyte imbalance, and
myocardial ischemia [42]. Sustained ventricular
tachycardia (VT) is emergently treated with lido-
caine as a first-line drug in a hemodynamically
stable patient. Synchronized cardioversion is the
treatment of choice for compromised patients.
Torsades de pointes, another form of VT, typically
occur in the setting of QT prolongation. Initial
treatment is with magnesium sulfate. Junctional
ectopic tachycardia (JET) usually occurs in the
first 24–48 h after surgery and is the most com-
mon postoperative arrhythmia in infants and chil-
dren less than 2 years of age [18]. The ventricular
rate is generally greater than 160 with a slower
atrial rate that may cause hypotension and
increased filling pressures. Complete heart block
(CHB) results from the complete dissociation of
the atria and ventricles leading to a low-output
state. It is usually transient in the postoperative
period and is treated with external AV sequential
pacing.
Although normothermia is the general goal of
temperature regulation, a mild degree of hypo-
thermia may be beneficial in the immediate post-
operative period. There may be a brief period of
temperature instability following congenital heart
surgery, and efforts should be aimed at limiting
wide fluctuations in body temperature. Induced
hypothermia may reduce oxygen consumption,
8 P. Lincoln et al.
limit the effects of tachyarrhythmias, and improve
neurological outcomes [43, 44]. However, a
decrease in body temperature may cause an ele-
vation in SVR and PVR, decrease cardiac output,
and potentially increase the risk of bleeding [26,
42]. Infants are especially vulnerable to cold stress
because of the high body surface area to weight
ratio and a limited ability to regulate body tem-
perature. Rewarming should occur gradually with
close monitoring.
Increased body temperature may result from
activation of the inflammatory response after
CPB or from low cardiac output. Hyperthermia
increases oxygen consumption and may increase
the risk of arrhythmias and neurological injury.
Active cooling strategies may be implemented to
limit the deleterious effects of hyperthermia in the
immediate postoperative period.
The use of intracardiac monitoring catheters
provides quantitative data for hemodynamic
assessment in the postoperative patient. Knowl-
edge of the patient’s specific cardiac anatomy and
details pertaining to the surgical repair or inter-
vention are necessary to correctly interpret any
information obtained. The catheters are placed
transthoracically into the right atrium (RA), left
atrium (LA), and/or pulmonary artery (PA). These
intracardiac catheters provide information on
heart chamber, great vessel pressures, and satura-
tions. This hemodynamic information also assists
in evaluating responses to pharmacological thera-
pies, mechanical ventilation changes, and fluid
administration. Chest radiograph confirmation of
catheter location is required, with waveform
assessment and the presence of blood return, to
assure functionality. Precise interpretation of pres-
sures or oxygen saturation depends on catheter
location and specific patient anatomy.
Reported risks of intracardiac catheter use
include malposition, thrombus formation, and
infection [45]. The LA and PA catheters are usu-
ally removed 24–48 h postoperatively, unless con-
tinued monitoring for LA or PA hypertension is
required. The RA catheter may remain in place for
an extended period to provide access for non-
traumatic blood sampling and administration of
vasoactive infusions, parental nutrition, or vol-
ume. Complications associated with the removal
of these catheters are hemorrhage, entrapment, or
fragmentation [45, 46]. Following guidelines in
regard to evaluation of hematological status,
patient hemodynamics, use of chest drains, and
availability of blood products for removal of intra-
cardiac catheters will decrease the occurrence of
complications and associated risks.
Right atrial (RA) or central venous monitoring
catheters provide information about systemic
venous return, vascular volume, and right ventri-
cle function. These catheters are placed directly
into the right atrium or internal jugular vein or
superior vena cava. Right atrial pressure (RAp) or
central venous pressure (CVP) is recorded as
mean pressure, and the value reflects patient pre-
load or right ventricle end-diastolic pressure
(RVEDP) if the tricuspid valve is competent
[42]. The average range of RAp or CVP is 1–
5 mmHg, though these may have a slight normal
elevation in the cardiac postoperative patient of 6–
8 mmHg. Elevated RAp or CVP may indicate
fluid overload, right ventricle (RV) dysfunction
or hypertrophy, problems with the tricuspid
valve, left to right intracardiac shunting, increased
pulmonary vascular resistance, cardiac
tamponade, or a pericardial effusion. Decreased
RAp or CVP usually indicates hypovolemia [24,
42]. Measurement of blood oxygen saturation
from these catheters will estimate systemic
venous or mixed venous oxygen saturation and
assist in evaluation of cardiac output [1].
Left atrial (LA) monitoring catheters provide
information about pulmonary venous pressure,
left heart preload, and left ventricle function.
These catheters are usually threaded through a
superior pulmonary vein across into the left
atrium. The average left atrial pressure (LAp) is
usually 1–2 mmHg greater than RAp. Of note,
LAp measuring less than 12–14 mmHg is fre-
quently tolerated in the postoperative patient [24,
42]. LAp is recorded as mean pressure and the
value reflects left ventricle end-diastolic pressure
if the mitral valve is competent. Elevated LAp
may indicate left ventricle (LV) dysfunction or
hypertrophy, problems with the mitral valve,
increased systemic vascular resistance, right to
left intracardiac shunting, volume overload, or
cardiac tamponade [24]. Persistently elevated
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
LAp may indicate the development of LA hyper-
tension. Decreased LAp may indicate hypo-
volemia. Normal oxygen saturation of the blood
in the LA is 100% [26]. Blood shunting from the
RA to the LA or the presence of pulmonary vein
desaturation will decrease this value [24].
Cannon waves occurring in RA or LA record-
ings usually indicate the loss of normal sinus
rhythm, as these waves occur when the atria con-
tracts against a closed valve [47].
Pulmonary artery (PA) monitoring catheters
provide information about mixed venous oxygen
saturations, RV function, right ventricular outflow
tract patency, pulmonary vascular reactivity, and
mean filling pressures on the left side of the heart
[1]. These catheters are threaded through the mus-
cular wall of the RV, across the RV outflow tract,
and into the main pulmonary artery. From there, it
may migrate into a branch pulmonary artery. The
pulmonary artery pressure (PAp) is recorded as
mean, systolic, and diastolic, with the systolic
value equal to the RV systolic pressure and the
diastolic value equal to the LAp if pulmonary
hypertension or mitral valve problems are not
present. The PAp usually measures 1/4 to 1/3 of
systemic blood pressure. The average mean PAp
is 15 mmHg, with a range of 10–20 mmHg. Dur-
ing the postoperative period, PAp as high as
25 mmHg may be tolerated [24, 26, 46]. Elevated
PAp may indicate an obstruction in the pulmonary
arteries such as an embolus, pulmonary hyperten-
sion, pulmonary vascular obstructive disease,
reactive airway, lung disease, the presence of aci-
dosis, a large left to right intracardiac shunt,
increased LAp, or mechanical obstruction of the
airway. Decreased PAp may indicate hypo-
volemia, decreased cardiac output, or obstruction
to pulmonary blood flow [24]. Continuous record-
ings done as the PA catheter is pulled back from
the pulmonary artery into the right ventricle may
indicate the pressure of a residual right ventricle
outflow tract obstruction in patients post-
Tetralogy of Fallot repair [47]. Oxygen saturation
values obtained from the pulmonary arteries are
true mixed venous saturations, with a normal
value of slightly less than 80%. High PA oxygen
saturation values may indicate the presence of a
9
significant left to right intracardiac shunt, possibly
a ventricular septal defect [26].
Mean PAp greater than 25 mmHg at rest con-
stitutes pulmonary hypertension (PHTN)
[48]. After surgery, the effect of PAp on patient
outcome depends upon many factors, especially
the preoperative RV pressure and the postopera-
tive circulation physiology. For example, a patient
with systemic level PAp preoperatively may tol-
erate ½ to ¾ systemic RV pressure well after
operation; however, a patient with Fontan physi-
ology will be seriously compromised by PAp
greater than 15–17 mmHg. Patients with
increased PVR preoperatively are more likely to
present with postoperative pulmonary hyperten-
sion than those with normal PVR [49].
The cause(s) of postoperative PHTN are not
well understood. Pulmonary vascular endothe-
lium dysfunction may be important in some
cases, and abnormality of vascular smooth muscle
and circulating vasoactive substances may all be
relevant. Injury related to the effects of cardiopul-
monary bypass (CPB) and activation of pulmo-
nary endothelial vasoconstricting mediators,
pulmonary leukosequestration, microemboli,
hypothermia, lung disease, blood product admin-
istration, and certain medications such as prot-
amine may all play a role [50]. During an acute
pulmonary hypertensive crisis, PAp exceeds sys-
temic blood pressure resulting in progressive right
ventricular dysfunction, reduced cardiac output,
and sometimes hypoxemia. In the patient with
Fontan physiology, increased PAp causes
decreased cardiac output and high central venous
pressure. During an acute crisis, patients with
existing intracardiac shunts may present with an
initial decrease in oxygen saturation [51]. Other
signs include tachycardia, hypotension, and ele-
vated end-tidal carbon dioxide (EtCO2) levels
associated with a lack of sufficient pulmonary
blood flow. Early intervention is required to
avoid bradycardia and impending cardiac col-
lapse. Acute interventions include mechanical
hyperventilation with 100% oxygen, administra-
tion of sedation and analgesia that may be com-
bined with pharmacologic paralysis, the use of
inhaled nitric oxide (iNO), and promoting a situ-
ation of respiratory alkalosis [48].
10
Postoperative PHTN from increased pulmo-
nary vascular resistance may be transient, but in
some case persist. Treatment strategies should
focus on proactive measures to prevent an acute
pulmonary hypertensive crisis and avoiding pre-
cipitatory factors including hypoxia, hypo-
ventilation, acidosis, alpha-adrenergic inotropes,
sympathetic stimulation, and environmental
stress. Administration of analgesics and sedation
prior to stressful procedures such as endotracheal
tube suctioning may be helpful in decreasing a
pulmonary vasoreactive response. Measures to
decrease pulmonary reactivity include
maintaining an alkalotic pH (which promotes pul-
monary vasodilation), providing sufficient right
atrial preload and cardiac output, managing RV
failure, ensuring patient comfort and analgesia,
and providing optimal mechanical ventilation
and oxygenation [51]. Adequate positive
end-expiratory pressure (PEEP) will assist in pre-
venting atelectasis and pulmonary vasoconstric-
tion, though excessive PEEP may be detrimental
by causing hyperinflation and elevated PVR [49,
51, 52]. Pulmonary vasodilator therapy with phar-
macologic agents may assist in decreasing pulmo-
nary vasoreactivity. Inhaled nitric oxide, a quick-
acting, selective pulmonary vasodilator, is cur-
rently the agent of choice, although it is not
always effective [53, 54]. Rebound PHTN associ-
ated with abrupt discontinuation of iNO may be
avoided by very slowly weaning iNO (especially
below 5 ppm) and a single dose of oral sildenafil
citrate.
Delayed Sternal Closure
Clinical and surgical management strategies that
maximize and promote cardiac output after pedi-
atric cardiac palliative or corrective surgery are
essential in decreasing morbidity and promoting
positive outcomes in the ongoing struggle with
congenital heart disease. One such strategy is the
surgical use of an open sternotomy followed by
delayed sternal closure (DSC) during the postop-
erative period in the PCICU. This technique was
first described in 1978 in a pediatric case report
and has continued to be utilized [55].
P. Lincoln et al.
After an extensive cardiac surgical procedure,
the myocardium may undergo a process of inflam-
mation and swelling. Due to the limited anatomi-
cal space in the pericardiomediastinal area in
infants and children, cardiac compression may
occur in this closed sternum environment. This
compression leads to a low cardiac output state
due to decreased ventricular compliance, filling,
and preload [56]. This phenomenon has been
described by different terms in the literature such
as tight mediastinal syndrome, cardiac compres-
sion, and typical and atypical tamponade [55, 57–
59].
The cardiovascular (CV) surgeon will either
electively or emergently leave the sternum open
to allow the patient to undergo recovery and
achieve an adequate state of cardiac output and
hemodynamic stability. Additionally, some
patients with an open sternum may require the
use of a rib spreader or a splinting device to lift
the sternal edges off the heart to further decrease
any remaining cardiac compression. A sterile
occlusive dressing is placed over the open ster-
num by the CV surgeon to prevent mediastinal
contamination and infection.
After the patient has achieved hemodynamic
stability and recovery, DSC will be surgically
performed either at the bedside or in the operating
room (OR). The time frame for the use of an open
sternum is patient dependent; however, a range of
18–40 h with a median time of 21 h has been
reported [60]. Clinical issues that may prevent
DSC include, but are not limited to, implantation
of a mechanical support device through the open
sternum or mediastinitis. In these situations, the
sternum will remain open with a sterile occlusive
dressing in place until the device is surgically
removed, or ongoing mediastinitis management
may include the use of a vacuum-assisted device
for DSC.
Experienced and technically advanced nurses
are required to provide minute-to-minute bedside
care for these critically ill pediatric patients. There
are two specific periods of recovery that require
special attention and focus. The patient recovery
periods are initially after returning from the OR
with an open sternum and immediately after
undergoing DSC.
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
After returning from the OR, the nurse’s ongo-
ing bedside assessments and interventions are
very system focused. Achieving and maintaining
optimal cardiac output is the key goal in this
recovery phase. The different indicators of cardiac
function, which may include heart rate, blood
pressure, filling pressures such as RAp, LAp, or
CVP, pulse oximetry, urine output, near-infrared
spectroscopy readings (NIRS), capillary refill, and
central and peripheral perfusion, are monitored
closely. The CV surgeon or intensive care medical
team will order interventions that are aimed at
improving any deficit in cardiac performance.
The nurse is responsible for administering the
intravenous fluid, medications, or ventilator
changes as ordered and providing the important
follow-up patient clinical assessments. Monitor-
ing for complications such as postoperative bleed-
ing is especially important. Patients who have
undergone cardiopulmonary bypass may return
from the OR with a potential for a coagulopathy
problem and may require monitoring of clotting
factors and the administration of blood products.
This recovery period is very busy and stressful.
The nurse demonstrates effective time manage-
ment and multitasking skills to meet the ongoing
clinical needs of these patients. The guidelines for
the care of the pediatric postoperative cardiac
surgery patient (see Table 1) provide a summary
of different specialized nursing interventions and
considerations for the initial recovery period [61].
Immediately after DSC, the nurse must be
aware of the physiological cardiopulmonary
changes that occur at the time of sternotomy clo-
sure and monitor for the corresponding hemody-
namic clinical indicators. With sternal closure, the
intrathoracic pressure increases which in turn
causes increased pressure and compression on
the heart and lungs. Multiple hemodynamic
changes have been demonstrated to occur at the
time of sternal closure [62, 63]. The cardiac
changes will be reflected in the patient’s blood
pressure, mean arterial pressure, and filling pres-
sures. Depending on the clinical indicators and
assessed markers of cardiac output, the patient
may require additional fluid administration and
initiation and/or titration of inotropic medication
infusions to assist and manipulate the patient’s
11
cardiac performance during this transition period.
From a respiratory standpoint, the patient will
experience decreased chest wall compliance at
the time of sternal closure, and this will in turn
impact patient oxygenation and ventilation. Mon-
itoring of breath sounds, chest wall excursion
during the phases of inspiration and expiration,
pulse oximetry trends, and follow-up chest radio-
graph after closure will provide the nurse with
important information about the patient’s oxygen-
ation and ventilation status. Ventilator changes
may have to be utilized to compensate for this
acute change in chest wall compliance and
improve overall patient oxygenation and ventila-
tion. Below is a summary of the hemodynamic
changes associated with chest closure (see
Table 2) [61].
The bedside nurse is the key individual in
providing ongoing clinical assessments and inter-
ventions for the patient undergoing open
sternotomy and DSC. Open and clear communi-
cation strategies utilized by the nurse and the
managing intensive care team and/or cardiovas-
cular surgeon are critical. The postoperative use of
open sternotomy and delayed sternal closure has
become a proven strategy in the surgical palliation
and/or repair for infants and children with con-
genital heart disease.
Use of Venoarterial Extracorporeal
Membrane Oxygenation (VA-ECMO)
In patients with cardiogenic shock that are failing
conventional medical therapies, mechanical circu-
latory support should ideally be initiated early to
improve survival and prevent end-organ dysfunc-
tion. Common indications for VA-ECMO in the
cardiac patient include failure to wean from CPB,
progressive low cardiac output, cardiopulmonary
arrest, profound cyanosis from intracardiac
shunting, pulmonary hypertension, intractable
arrhythmias, and respiratory failure [64,
65]. VA-ECMO may be used for short-term sup-
port of the heart until the return of intrinsic myo-
cardial function, as a bridge to transplant or as a
bridge for longer-term support with a ventricular
assist device when myocardial recovery duration
12 P. Lincoln et al.

Table 1 Guidelines for care of the pediatric postoperative cardiac surgery patient
Patient identification
Bag/mask at bedside with fractional inspired oxygen (FiO2) set appropriately for patient diagnosis
Suction available
Monitor alarm limits on and set appropriately for age and diagnosis
Paced setting on/off as appropriate
NBP cuff of appropriate size
Emergency medications and vasoactive infusions dose information
Vital signs monitored – heart rate, arterial blood pressure (ABP)/noninvasive blood pressure (NBP), RAp, LAp, PAp,
and CVP are recorded
Review heart rate and rhythm – note regularity and assess for bradycardia/tachycardia, arrhythmias
Temperature recorded every 2–4 h (consider continuous temperature monitoring for labile neonates or patients actively
being cooled)
Review invasive line waveforms and placement on CXR – interpret values
Four extremity NBP on admission of newborn, and then every shift and prn for patients with obstruction to systemic
blood flow lesions
Obtain and document PR interval (every shift and prn)
12-lead ECG on admission and with arrhythmias; consider need for atrial wire tracing prn
Pacemaker setting checked every hour and prn – knowledge of underlying rhythm
Assessment of heart sounds for presence of murmurs (continuous murmur with patient on prostaglandin E 1 (PGE 1)
infusion and patent ductus arteriosus (PDA) or patient with Blalock-Taussig shunt (BTS))
Assessment of perfusion – warmth of extremities, capillary refill time, presence of differential between core and
peripheral temperature
Assessment of central and peripheral pulses (0 absent, 1+ barely palpable, 2+ normal, 3+ full volume, 4+ bounding)
Record amount and characteristics of all chest tube drainage hourly as needed
Assess respiratory rate and depth, evidence of distress, and quality of breath sounds every 2 h and with change in clinical
status
Check endotracheal tube (ETT) placement on CXR
Identify patients at high risk for decompensation with ETT suctioning (patients with sensitive PVR)
Suction ETT once a shift and when clinically indicated: document breath sounds before and after intervention
Assess and document ventilator settings and monitored parameters every 2 h and when arterial blood gas (ABG) drawn
or ventilator changes made
Assess and document EtCO 2 hourly and with ABG analysis
Ventilator FiO 2 set no lower than.30 to.40 for all patients except:
patient with a BTS or ductal-dependent lesion
Ambu bag set at 100% for all patients except:
patient with BTS or ductal-dependent lesion – room air or 10% greater than vent
Assess level of consciousness (LOC), orientation, and baseline behavior on admission and hourly as indicated
Assess movement and strength off all extremities
For patients <2 years of age – Head circumference on admission
Auscultate bowel sounds
Assess and document abdominal girth on patient <1 year of age on admission, once a shift, and every 4 hours while
advancing feeds
Assess stool for color, consistency, and presence of blood
Daily calorie calculation for patients <1 year of age, NPO patients, and patients receiving IV nutrition or tube feeding
supplementation
Monitor serum laboratory results
Hourly documentation of all intake and output
Assess response to diuretic therapy
Skin assessment (including back and gluteal fold) on admission and with each turn
Turn/reposition patient every 2 h
Assess skin under medical devices prn as needed
Assess all surgical sites and need for dressings
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
Table 2 Hemodynamic changes associated with chest closure
Cardiac
Blood pressure No change or
decrease
Mean systemic arterial No change or
pressure decrease
Filling pressures Increases
Central venous pressure
Right atrial pressure
Left atrial pressure
Respiratory
Decreased chest wall Changes in
compliance ventilation
Changes in
oxygenation
Based on data from Main et al. [62] and McElhinney et al. [63]
is greater than expected or not anticipated. A
system for rapid deployment of ECMO during
resuscitation, or extracorporeal cardiopulmonary
resuscitation (ECPR), necessitates the appropriate
resources and personnel for full time in hospital
coverage. This requires a skilled team including
nurses, cardiac surgeons, ECMO therapists, car-
diac intensivists, respiratory therapists, and con-
sultation with specialty services that include
hematology, neurology, cardiac transplantation,
social services, child life, and pastoral care. The
ECMO specialist works directly with the bedside
nurse and members of the interdisciplinary team
and is responsible for maintaining the circuit,
minimizing circuit-related complications, and
managing circuit emergencies.
Once the patient is stabilized on ECMO and
adequate flow is established, it is necessary to
identify any possible causes for patient decom-
pensation. A chest radiograph is obtained to eval-
uate cannula placement, and blood tests are
performed to assess tissue perfusion and
end-organ function. Laboratory tests include eval-
uation of acid–base balance, serum lactate, mixed
13
Administration of fluids
Initiation or titration of infusion(s) of inotropic medications
Monitor for signs and symptoms or markers of decreased cardiac
output
Obtain echocardiogram to assess for function and tamponade
Administration of fluids
Initiation or titration of infusion(s) of inotropic medications
Monitor for signs and symptoms or markers of decreased cardiac
output
Monitoring for changes in preload
Administration of fluids
Administration of diuretic
Monitor for signs and symptoms of tamponade
Manipulate minute ventilation by changing rate or title volume
Obtain follow-up arterial blood gas analysis to assess patient
response
Manipulate with change in positive end-expiratory pressure or
oxygen percentage
Obtain follow-up arterial blood gas analysis to assess patient
response
venous saturation, renal and hepatic function
tests, and hematological studies as well as evalu-
ation of urine output [65]. Patients may benefit
from a mild degree of hypothermia in the first 24 h
to prevent the progression of further neurologic
injury [66]. Temperature is adjusted accordingly
via the heat exchanger from the ECMO circuit,
and a continuous temperature monitoring may be
initiated. The patient should be evaluated for
increased LV wall stress and left atrial hyperten-
sion from aortic cannula position and poor LV
function predisposing the patient to excessive
LV dilation, pulmonary edema or hemorrhage,
and prolonged myocardial recovery [67,
68]. Echocardiography and clinical analysis are
indicated to diagnose this problem. Left atrial
decompression may be accomplished with a vent
placed from the LA to the venous side of the
circuit in the patient with an open sternotomy
incision or by transcatheter approach to create an
intra-atrial communication [68]. While supported
with ECMO, patients are at risk for significant
complications including bleeding, thromboem-
bolic injury, neurological insult, infection, renal
14
dysfunction, and multisystem organ failure [69–
71].
Monitoring of cardiac output and hemody-
namic parameters is accomplished with the con-
tinuous assessment of heart rate, rhythm, arterial
and venous blood pressures, and tissue perfusion.
Despite adequate tissue perfusion in the presence
of unstable arrhythmias while on ECMO, mea-
sures to restore atrioventricular synchrony should
be taken since myocardial distension and poor
recovery of ventricular function may otherwise
ensue. This may be achieved with the stabilization
of electrolytes, antiarrhythmic therapies, cardiac
pacing, and defibrillation or cardioversion
[72]. Typically, mean arterial and venous pres-
sures are monitored since ECMO flow is rela-
tively nonpulsatile causing pressure waves to
dampen. Venous and intracardiac pressures are
generally low. Elevated filling pressures are sug-
gestive of cardiac tamponade or decreased myo-
cardial function [72]. Mean arterial pressure
(MAP) varies according to the size and age of
the patient and is generally adequate if 35–
45 mmHg is attained in neonates or greater than
60–70 mmHg in larger pediatric and adult patients
[72]. ECMO circulation is dependent on adequate
preload and avoidance of increased afterload.
Fluid should be readily available to manage hypo-
volemia along with blood products to treat abnor-
mal hematologic parameters (see Table 3).
Providing a level of inotropic support may assist
with assisting intrinsic cardiac ejection and
maintaining adequate blood pressure if needed
[73]. Increased SVR may inhibit the forward
flow of ECMO and inhibit tissue perfusion.
Excessive use of inotropes, hypothermia,
tamponade, or mechanical problems may all con-
tribute to increased afterload and should be
avoided. Pharmacologic measures for afterload
reduction may be accomplished with phosphodi-
esterase inhibitors such as milrinone, vasodilators,
and beta-adrenergic blockers [65]. Analgesics and
sedatives are often used to manage patient pain
and agitation as well as to minimize the effects of
pulmonary and systemic vascular resistance.
Once on full ECMO support, mechanical ven-
tilation should be adjusted to maintain adequate
pulmonary venous saturation and coronary
P. Lincoln et al.
oxygenation [72]. Physical exam, lung compli-
ance, arterial blood gas analysis, and chest radio-
graph results are used to manipulate ventilatory
support. If increased PVR is present, vasodilator
therapy or iNO may be helpful as indicated. Gen-
eralized opacification of the lungs often develops
within 24 h following cannulation as a result of
capillary leak and inflammation from blood con-
tact with ECMO surfaces. This can also be a
consequence of left atrial hypertension and
requires urgent decompression of the left atrium.
The airway should be maintained as needed with
routine pulmonary toilette with gentle endotra-
cheal tube suctioning. Caution is required to pre-
vent pulmonary hemorrhage.
Hemorrhage and thromboembolic events are
common complications while on mechanical cir-
culatory support [73]. Blood contact with the for-
eign surfaces of the ECMO circuit stimulates
complement and clotting cascades causing the
activation of multiple blood components. This
predisposes the patient to a chronic inflammatory
state and thromboembolic events [72]. An imma-
ture hematologic system may complicate the anti-
coagulation course in the pediatric patient on
mechanical circulatory support. Routine monitor-
ing includes assessment of activated partial
thromboplastin time (aPTT), prothrombin time
(PT), fibrinogen, unfractionated heparin level,
hematocrit, platelet count, activated clotting time
(ACT), and antithrombin III levels (AT III) (see
Table 1). Heparin is the anticoagulant that is com-
monly used to avoid complications related to
coagulopathy. Heparin binds to AT III to suppress
the coagulation effects of factor X and fibrin. If AT
III levels are inadequate, heparin response may be
suboptimal. Treatment with AT III or fresh frozen
plasma (FFP) assists in maintaining therapeutic
AT III levels. In addition, thromboelastograph
(TEG) analysis is used to assess time to clot for-
mation as well as specific properties of thrombus
and may be helpful in monitoring and diagnosis of
coagulation issues during ECMO support
[72]. An anticoagulation monitoring protocol
may be helpful to provide a standardized approach
to managing hematological parameters, decrease
circuit interventions, and minimize complications
of bleeding and clotting.
Pediatric Cardiac Intensive Care – Cardiovascular Management: Nursing Considerations
Table 3 Therapeutic hematologic values for the patient on
VA-ECMO
PT <17 s
aPTT 60–80 s
ACT 180–210 s
Fibrinogen >100 mg/dl
Unfractionated heparin 0.3–0.7 IUnits/ml
Antithrombin III >70%
Platelet count >100,000
Hematocrit 35%
Patients are at significant risk for hemorrhage
related to coagulopathy and anticoagulation
requirement. Those who are cannulated in the
perioperative phase are especially at risk due to
fresh suture lines, dilution of clotting factors,
hypothermia, low oxygenation, and acidosis
[72]. Unfractionated heparin levels, aPTT, ACT,
and other anticoagulation tests may need to be
adjusted accordingly if significant bleeding is pre-
sent. Bleeding may occur from surgical incisions
and drains as well as within major organ systems
including the cranium, abdomen, and lungs.
Hypertension should be avoided to minimize
bleeding. Venipuncture and arterial punctures as
well as invasive or potentially traumatic proce-
dures should be avoided whenever possible. In
order to avoid bleeding, caution should be taken
with endotracheal tube suctioning and when
inserting nasogastric (NG) or nasojejunal
(NJ) tubes. The appropriate blood products,
including platelets, packed red blood cells, FFP,
and cryoprecipitate, are used to treat non-
therapeutic levels and coagulopathy (see
Table 3). Exposure to blood products should be
limited in order to avoid sensitization of the
patients and the formation of associated anti-
bodies that may compromise future organ trans-
plantation compatibility.
Postcardiotomy patients are at greater risk for
cardiac tamponade, inhibiting venous return to the
ECMO circuit and compromising systemic circu-
lation. Chest tubes must remain patent to allow for
drainage of blood from the chest cavity, and
patients with open sternotomy incisions require
continuous assessment of the site to ensure a
concave appearance. Signs of cardiac tamponade
15
include tachycardia and elevated intracardiac and
central venous filling pressures and convex
appearance of open sternotomy dressing with sub-
sequent hypotension. These signs may present
with increased chest tube output or sudden cessa-
tion of drainage. Immediate surgical exploration
of the chest is required.
Neurologic injury, including brain death,
infarction, or intracranial hemorrhage, is a com-
mon complication of ECMO support [74–
76]. Careful assessment of the patient’s neuro-
logic status including hourly pupil response in
the sedated and anesthetized patient, level of con-
sciousness, and assessment for seizure activity is
warranted. Infants with an open fontanel should
have a routine head ultrasound performed every
2 days or more frequently as needed to assess for
intracranial hemorrhage [65]. Routine neurology
consult following ECMO cannulation is indicated
for both short- and long-term assessment of neu-
rological status.
While analgesics and sedatives are used to
provide patient comfort, it is necessary to avoid
pharmacologic muscle relaxants as possible to
promote optimal neurological exams and sponta-
neous respiratory effort as appropriate. Analgesics
such as morphine and benzodiazepines are often
used to promote comfort and decrease pain and
anxiety while on ECMO support. Inhaled anes-
thetic agents, such as isoflurane, may also be used
[77]. Once the patient is weaned from muscle
relaxants and anesthetic agents, developmentally
and physiologically appropriate pain scales are
helpful in pain management.
Cardiac patients on ECMO support are at high
risk for infection from multiple central and periph-
eral venous and arterial access sites, surgical inci-
sions, prolonged mechanical ventilation, invasive
catheters and tubes, and immune-compromised
state [70]. Antibiotic and fungal prophylaxis is
indicated to prevent infection while receiving
mechanical circulatory support. Typical signs of
infection may be unreliable while on ECMO sup-
port since temperature is regulated by the heat
exchanger, and thrombocytopenia may occur as
a result of platelet destruction by the ECMO cir-
cuit. Routine complete blood count and cultures
16
while on support may be indicated to rule out
infection [65].
Once on ECMO, aggressive fluid management
is warranted for most patients due to fluid over-
load from resuscitation, low cardiac output, renal
dysfunction, or capillary leak from CPB prior to
cannulation [72, 77]. Fluid overload is managed
with pharmacologic therapies including furose-
mide, fenoldopam, renal range dopamine, and
other diuretic agents. Renal dysfunction is a com-
mon complication of mechanical circulatory sup-
port and a predictor of mortality for patients on
ECMO [70, 78, 79]. Accurate assessment of urine
output, correction of electrolyte imbalance, and
monitoring renal function tests are indicated.
Efforts should be directed at promoting intrinsic
urine output. Ultrafiltration, continuous
venovenous hemofiltration, or dialysis may other-
wise be indicated.
Children with complex congenital heart dis-
ease are at high risk for growth failure [80]. Tradi-
tionally, parental nutrition has been the preferred
method of optimizing nutrition in pediatric car-
diac patients supported on VA-ECMO because of
the risks associated with inadequate gut perfusion.
The effects of high-dose vasopressors on the gas-
trointestinal system prior to initiating ECMO [81]
and the alteration in gut function secondary to
CBP [82] may increase the risk of developing
necrotizing enterocolitis. Use of enteral nutrition
in neonates on VA-ECMO was found to be well
tolerated with few complications [81].
Patients on ECMO support are at risk for pres-
sure ulcers (PU) and decreased circulation from
immobilization, potential compromised tissue
perfusion, and poor nutrition. Patient position
should be changed every 2 h, and skin and pres-
sure points are assessed routinely. Due to the size
and distribution of mass, infants and smaller
patients are at risk for developing pressure ulcers
on the occipital area, while older patients are at
greater risk for pressure-related wounds on sacral
areas [83]. Despite site of cannulation, the patients
head and body should be turned slightly at routine
intervals as possible to decrease the incidence of a
PU. In the patient with femoral ECMO cannulas,
body alignment should be maintained enough to
maintain ECMO flow and to avoid potential nerve
P. Lincoln et al.
damage to the lower extremities. In these patients,
distal perfusion may be compromised enough to
consider a jump graft to provide adequate distal
limb circulation.
Parents with critically ill children requiring
invasive life support are predisposed to feelings
of helplessness and anxiety related to fear of their
child’s suffering, neurologic injury, or death
[84]. The bedside nurse is in a critical position to
provide information and organize communication
with the interdisciplinary team especially during a
time of uncertainty regarding patient prognosis
and survival. Honest and open dialogue with fam-
ilies is crucial for building trust and to assist in
guiding decisions. Support from social work,
child life, and pastoral care services play a valu-
able role in assisting families in crisis.
Time on ECMO is variable and dependent on
myocardial recovery or decision to transplant,
transition to a longer-term mechanical support
with a ventricular assist device, or withdrawal of
support for severe, irreversible, and end-organ
dysfunction. Decannulation from ECMO support
is attempted after signs of myocardial recovery are
apparent with trials on decreased ECMO flow
rates. Echocardiography, evaluation of pulsatile
blood pressure, hemodynamic status, acid–base
balance, serum lactate, and mixed venous satura-
tion are used to determine readiness for
decannulation [72]. Mechanical ventilatory sup-
port should be adjusted to provide optimal oxy-
genation and ventilation, and vasoactive infusions
are in line and administered as needed to support
cardiac output. The patient should receive ade-
quate analgesia, sedation, and muscle relaxants
to decrease stress. If the patient tolerates low
flow of less than 15% prior to clamping and ade-
quate tissue oxygenation and perfusion for at least
60 min with the circuit clamped, decannulation
may be attempted [72].
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